A note on terminology: A person who is forced to leave their home but remains within their own country is called ‘an internally displaced person’. If they are then forced to leave their own country and seek refuge in a second country, they then become ‘an asylum seeker’. After a determination process, they then become a ‘mandate refugee’ or, in New Zealand, a ‘convention refugee’. Less than 1% of mandate refugees are resettled in a third country. Many countries, including New Zealand, take an annual quota of mandate refugees, ‘quota refugees’, and it is to this group which this paper is addressed; asylum seekers are not included. However, once a person is accepted into the New Zealand quota refugee programme, they become a permanent resident; strictly speaking, quota refugees in New Zealand should be called ‘former refugees’, but for simplicity they will be referred to as refugees. The whole process referred to above comes under the aegis of the United Nations High Commissioner for Refugees (UNHCR).

*

New Zealand’s refugee resettlement programme started officially in 1944 with the arrival of 800 Polish people. Following that, different groups of varying size and nationality arrived each year. In 1987, the New Zealand government decided on a fixed quota of 750 per year, which was increased to 1,000 in 2015 and 1,500 in 2020. New Zealand thus follows 34 other countries in taking an annual quota of refugees for resettlement.1

Accommodation on arrival in New Zealand before 1979 was under the care of an interdenominational church group, the Inter-church Refugee Committee, and was ad hoc. For example, in former army barracks and immigration and workers’ hostels.2

In 1979 the Mangere Refugee Resettlement Centre (MRRC) opened in a former army barracks built for the US Army in 1942 and used, since the war, as an immigration and workers’ hostel.3,4 Since 1979, all refugees being resettled in New Zealand stay in MRRC on arrival. In 2016 a new dedicated refugee resettlement centre was opened on the old site, and the original buildings were demolished. MRRC is under the care of the New Zealand Immigration Service (NZIS) and is a ‘one-stop shop’ with all the services needed for the resettling refugees on the one site, which includes medical, dental, psychological, educational and social.

Between 1979 and early 2020, the refugees arrived in intake groups every eight weeks and stayed for six weeks. Between 1979 and 2015 the intakes were approximately 125 in size, and from 2015 to 2020 they were approximately 170 in size. From 2020 it is planned that the intakes will be approximately 220 and the refugees will stay for only five weeks.

Before 2013, the refugees received little or no overseas medical screening. Since 2013 they have received limited medical screening carried out by the International Organisation for Migration (IOM). The screening includes a chest x-ray, an HIV test for adults and a clinical examination. The screening results are sent to MRRC.

During their stay at MRRC, the refugees are prepared for resettlement in New Zealand, and before early 2020 this included a comprehensive medical screening carried out by the on-site medical clinic, Refugee Health Screening Service (RHSC). The medical clinic was a government-run organisation, independent of NZIS; from 2000 until 2020, the clinic was part of the Auckland Regional Public Health Service (ARPHS).

Health data collected at MRRC from 1979 until 2020 is unique in the world. As far as is known, in no other country do all resettling refugees stay in the one site and receive medical screening. Data from other countries may be larger than that from MRRC, but it is always only a sample of the resettling population.

The increased number of refugees planned for in late 2020 has led to a radical change in health screening and management. It is planned that all refugees will receive comprehensive screening overseas and a limited assessment on arrival, and ARPHS will withdraw from providing services, which will be taken over by a general practice service whose configuration is unknown at the time of writing.5 Thus, comprehensive on-shore screening data will no longer be obtainable for the first time in 40 years.

Obviously there have been many other changes at MRRC since 1979. One of the most important, and one not confined to refugees in general and New Zealand resettling refugees in particular, is a major change in the health profile.

From its opening in 1979 until relatively recently, the health profile was one of deficiency and infectious diseases, particularly gut parasites. Now the major burden, and one felt in all countries receiving refugees, is the classical non-communicable diseases (NCD), such as diabetes and hypertension.

A paper published by the author (in collaboration with another author) in 2005 analysed the health profile of resettling refugees passing through MRRC between 1995 and 1999 inclusive.6 To explore the change in health profile, and other changes, the health of refugees resettling between 2010 and 2014 (before the increase in numbers) was analysed. For the purposes of this paper, the population of the 2005 paper will be called the original group (OG) and that of 2010–2014 the later group (LG). As noted below, some data from medical officers’ written annual reports from the opening of the refugee centre in 1979 to 1991 is used, and this group is called the historical group (HG).

Method

The medical screening the refugees received consisted of a battery of tests and a standardised clinical examination with the assistance of trained medical interpreters.

The battery of tests consisted of core tests, such as full blood count, and conditional tests determined by the person’s age and sex. For example, children up to their 15th birthday received a Mantoux test as part of screening for tuberculosis.

While the core and conditional tests were mandatory, others were voluntary. For example, sexually active women were offered cervical smear screenings and microbiological screenings for sexually transmitted infections (STI) and other genital infections, which were purely voluntary.

Where indicated, further testing might be done. For example, those found with macrocytosis on their full blood count would receive testing for vitamin B12 and folic acid.

All results were entered on a computerised patient management system (PMS): the OG on a purpose-built Microsoft ACCESS programme, and the LG on a commercially available PMS, Medtech32.

In addition, written annual records produced by medical officers at MRRC between 1979 and 1991 were examined for historical data which was used in the original paper, and some has been included in the present paper, the historical group (HG).

The author had access to the data from the OG and, in some cases, was able to re-work the data to make it comparable with the LG.For example, the referrals to secondary services.

Those refugees found to have problems were either treated during their stay, if necessary referred urgently to hospital for inpatient or outpatient management, or referred to a primary care doctor or outpatient clinic in their city of resettlement after they had left MRRC.

Results

Demography

Figure 1: Age/sex distribution of OG, 1995–1999.6

Figure 2: Age/sex distribution of LG, 2010–2014.

The total number of refugees in each of the ‘Christmas tree’ graphs above are similar—2,992 for the original group and 3,530 for the later group. This is to be expected, as the planned annual intake was 750 from 1979 until 2015. Hence, over five years, 3,750 refugees would expect to be resettled, though in both groups that target was never reached.

The graphs show that in general the population is a young one—though the ‘tip’ of the graph is in fact higher in the later group, with the presence of those of advanced age in later group, a phenomenon familiar to those working with refugees.

The graphs also show a balance between males and females: 47% female and 53% male in the original group, and 49% female and 51% male in the later group. This is a consequence of the New Zealand policy of accepting predominantly family groups.

What the graphs do not show is the marked change in the origins of the refugees between the two groups.

In the original group, the top two nationalities were Iraqi and Ethiopian, making up 52.3% of the group, while in the later group, the top two nationalities were Burmese and Bhutanese, making up 50.9% of the group. In the later group, Iraqi make up 10% of the intake and Ethiopian only 0.2%. There were no Burmese or Bhutanese in the original group. The reasons for these changes will be discussed.

Infectious diseases

Tuberculosis

Tuberculosis (TB) control has always been the main focus for infectious disease control in quota refugees and shows considerable success over the years. The results will be presented as (1) overall results, (2) a focus on TB in childhood and (3) a note on abnormal chest x-rays.

Overall outcome of tuberculosis testing

Figure 3: Outcome of tuberculosis testing in refugee screened OG, 1995–1999.6

Figure 4: Outcome of tuberculosis testing in refugee screened LG, 2010–2014.

The graph from the original paper has been left in its original form. The differences between the graphs shows not just the marked reduction in TB disease from a point prevalence rate of 2% to 0.18%, but it also demonstrates (1) different management in TB testing, (2) improved access to the final outcome of TB testing in refugees and (3) diagnosis and treatment of TB disease before arrival in New Zealand, which was present in the later group but not the original group.

In the original group, only 65% were assigned as discharged from testing, while in the later group, 93% were discharged. This is because:

1. Nine percent of refugees in the original group were enrolled for serial chest x-rays after leaving (see the ‘CXR 9%’ section of the original group graph). No refugees in the later group were enrolled for serial chest x-rays.
2. In the original group, the whole group received Mantoux testing, while in the later group, Mantoux testing was done only up to the 15th birthday. Further, the level of Mantoux was lower in the original group for the starting of treatment for latent TB infection (LTBI). Hence the ‘prophylaxis 13%” includes treatment for LTBI in adults and children. The ‘LTBI 6.76%’ in the later group refers only to children. The changes were brought about mostly after consideration of a paper that outlined the cost/benefits of different methods of screening refugees and immigrants.7
3. At the time of the publication of the original group data, it was very difficult to track the final outcome of TB testing, hence the ‘Unresolved 11%’. In the later group, due to improvements in national data collection, it was possible to track the outcome of all TB testing, hence there is no “Unresolved’ section. So, the point prevalence of 2% TB disease in the Original Group is a minimum, as some of the ‘Unresolved’ group would have been found to have TB disease.

In summary, point prevalence of TB disease in resettling refugees:

Table 1: Summary of TB prevalence, 1980–2014.

TB testing in refugee children

The changes in outcome and management are even more marked in children.

Table 2: TB testing and results in children.

Overall, the proportion of children referred for assessment at the paediatric TB clinic between the OG and the LG is about the same, but the outcomes are very different. TB in refugee children is now virtually unknown, and the much higher proportion of those receiving treatment for LTBI in the LG represents a change in policy where treatment for latent TB infection was started at a lower level of Mantoux result, probably because of the high rates of TB disease in children.

The way in which data from the historical group are presented does not allow for analysis in children. But in one report, the medical officer reported that there were six children with TB disease in one intake of 125 people. As can be seen, TB disease in refugee children is now a rare event.

Abnormal chest x-rays

This section is included to remind practitioners that ‘Old TB’ recorded on a chest x-ray report does not exclude infectious TB disease. While signs of active TB may be present on a chest x-ray, their absence does not mean that there is no infectious TB present, which can be diagnosed only by such methods of PCR, microscopy and culture of induced sputum.

All refugees 12 years and over received a chest x-ray on arrival in New Zealand, in addition to having a chest x-ray overseas. The table below summarises the situation.

Table 3: Abnormal CXR in resettling refugees.

The outcome of the follow up for the abnormal chest x-rays cannot be ascertained for the historical and original groups; but for the later group, all abnormal chest x-rays were referred to respiratory service specialists for their opinion, and 70% needed some form of follow-up, usually induced sputum testing.

HIV and other infectious diseases

The rate of HIV infection shows another difference between OG and LG. In the LG, HIV testing was undertaken before arrival in New Zealand. A positive diagnosis does not prevent resettlement in New Zealand, but only 20 refugees with HIV can be taken each year.20 No pre-arrival testing was done for HIV in the HG.

In the LG, 16 refugees were confirmed to have HIV; all but two were known to have HIV before arrival and most were on medication. In the original group, none were known to have HIV before arrival, and hence none were on medication.

There is no data for the historical group; the first case of HIV infection was diagnosed in New Zealand in 1984, but routine testing of refugees after arrival did not start until 1993.

Table 4: Results of HIV testing in New Zealand.

Serology of infectious diseases other than HIV infection

Table 5: Serology of selected infectious diseases, 1980–2014.

• Hepatitis B: The screening test is hepatitis B surface antibody and surface antigen, with the antigen being the priority if insufficient blood is taken. If the person is found to be surface antigen positive, Hbe antigen, Anti Hbcore and antiHbcore (IGM) are also tested. (Those found to be carriers have further testing and are managed according to local protocol.)
• Hepatitis C: Screening test was hepatitis C antibodies. Those found with any level of antibody were tested for hepatitis C PCR.
• Treponemal disease: Screening—electrochemiluminescence-based assay. Reactive (ie, abnormal) screens tested by TPPA and RPR.

Alimentary tract infections

Intestinal parasites

Data is available for HG, OG and LG and again show a reduction in rates of infection in the historic group. It is not possible to give exact numbers, but the medical officers recorded rates of at least 30% in each intake of refugees, and some intakes with rates of 45% infection.

Table 6: Refugees affected by gut parasites 1980–2014.

Table 7: % of each group affected by four commonest parasites, 1980–2014.

Note that in Table 10, the percentage figures do not equal the total number affected, because (1) some people may have up to four parasites and (2) only the common parasites are recorded.

Burmese refugees and the effect of type of residence before arrival on gut parasite infection

Most refugees do not now come from refugee camps but have lived in some form of housing subsidised by UNHCR before coming to New Zealand.

The LG study had refugees from Burma, some of whom had a traditional origin from refugee camps in Burma, and some had been living in Malaysia and adjacent areas in subsidised housing. This gave an opportunity to study the effect of residence on prevalence.

In total, there were 1,113 Burmese refugees; 697 were from Malaysia, of which 95 people (13.6%) were affected by gut parasites. By contrast, 416 were from Thai refugee camps, of which 107 (25.7%) were affected by gut parasites.

Helicobacter pylori

At the time of the original paper, helicobacter pylori (H. pylori) infection was recognised, but simple testing became available only late in the study group.

There are now two tests available: (1) the stool antigen test and (2) the blood EIA antibody test.

Testing for H. pylori in the OG and LG group was triggered by the presentation at screening of dyspepsia and/or gastro-oesophageal reflux. This was done only for those 18 years and over. Those who were younger were usually referred for assessment by paediatric services. It is known that proton pump inhibitors (PPI) can affect the reliability of the stool antigen test, so when the person was found to have been taking PPI up to one month before screening, the antibody test was requested, sometimes together with the antigen test when the history of PPI intake was not clear.

In the OG, only 11 EIA tests were requested, of which eight (72%) were positive.

In the LG, 405 tests were requested: 364 stool antigen, of which 238 (65.4%) were positive, and 41 blood antibody tests, of which 16 (39%) were positive.

Included in the above results are five people who had both antigen and antibody tests requested, of which both were negative in four people and positive in one person. There were no discordant results.

Hereditary haemolytic blood disorders

All refugees have been routinely tested for haemoglobinopathies and other disorders (eg, G6PD deficiency when indicated). Counselling was offered for all affected families, and specialist referral where indicated. Note that in these series, there were no transfusion dependent disorders.

Table 8: % of refugee population affected by hereditary blood disorders.

Micronutrients

Micronutrients are substances ingested or otherwise assimilated in small quantities that are essential to health.

Results

No data are available from the historic group. In both OG and LG, all refugees were routinely tested for iron, and both groups were also tested for B12 and folate deficiency when indicated, usually the presence of macrocytosis or on dietary history.

Table 9: Refugees affected by lack of micronutrients.

Vitamin D

Only the later group was routinely tested. For this group, a total of 1,405 people were diagnosed as having reduced vitamin D levels, a prevalence of 39.8%. Prevalence by gender: female 47.4%, male 32.4%.

Table 10: % vitamin D deficiency by ethnicity, later group.

Vitamin D and iron

Two hundred and forty-three people had both iron and vitamin D deficiency, so one can be seen as a risk factor for the other.

Lifestyle

BMI

Table 11: BMI of OG and LG.

Tobacco use

Table 12: % of refugees using tobacco, 18 years and over, by gender OG and LG.

Gender-related issues

Sexually transmitted infections

Table 13: Sexually transmitted infections by group and gender. Overall = % of total population, male:female ratio of those affected, OG and LG.

Female specific

Contraception

Table 14: Contraceptive methods recorded on arrival, % of women interviewed, OG and LG.

These data should be interpreted with caution: for the OG only 171 women were recorded, and for assessment for contraception and for the LG, 554.

Pregnancy

Pregnancy testing was not routinely offered. Women known to be pregnant were made known to MRRC before arrival, by IOM. Shortly after arrival, all women who knew or thought they might be pregnant were invited to attend the clinic for confirmation, and if pregnancy was confirmed, further routine testing was done and they were followed up by a visiting midwife.

Table 15: % of women >12 years of age, pregnant, OG and LG.

Cervical smear screening

All sexually active women of the appropriate age were offered cervical smear screening. The test was voluntary. In all cases, whether the test was done or not, subsequent healthcare providers were alerted, and the women were put on the national register, unless they opted out.

Records were available for the OG and LG. No screening was done for the HG.

Table 16: Results of cervical smear screening OG and LG.

Psychological health

Psychosocial trauma is experienced by most refugees. For some it is what affects them most and is the priority for their care.

The need for a specialised psychological service for refugees was raised by the doctors at the medical clinic at MRRC from its opening in 1979, but such a specialised service, Refugees as Survivors New Zealand (RAS), did not open until 1995.

Paradoxically, this has meant that data about the psychological diagnoses for the refugees is not available from the medical-clinic records. This is because RAS is an autonomous organisation and is responsible for the ongoing psychological care of the refugees, independent of the medical clinic. It had close relations with the medical clinic and fed clinical information back to the clinic, but diagnostic categories were not always entered into the medical clinic’s PMS. Referrals to RAS were the single largest referral to secondary services (see Table 19), but other organisations could refer refugees to RAS, and the refugees could refer themselves. For example, in 2015 RAS reported that approximately 50% of the intake for the year were seen by RAS at MRRC. Ninety percent of those referred received psychological or counselling support and 10% of referrals were seen by the RASNZ psychiatrist.8

As part of the clinical assessment, a simple assessment of mental health was made by the clinic of the LG to assist in deciding whether to refer someone to RAS. This simple assessment was also part of the screening process for the OG. A previous study related to that OG found that about 20% of refugees had been subjected to significant mistreatment, 14% had reported some form of significant psychological symptoms and 7% were diagnosed with post-traumatic stress disorder.6

For the HG, the written records refer to psychological illness and some referrals made to psychological services, but no consistent data is available.

There is published information available about the mental health of refugees.9

Chronic illness and its effect upon service delivery

The effect of chronic illness will be explored under the three areas:

1. prevalence of certain chronic illnesses, where comparison can be made
2. prescribing patterns
3. intervention patterns of primary care doctors.

Prevalence of chronic diseases

Two typical and important chronic diseases are diabetes and hypertension, which will be used as exemplars. Because the numbers of the OG and LG are similar (2,995 vs 3,530), absolute numbers will be given to show the impact. HG figures are included and will be commented on in the conclusion.

Table 17: NCD, 1980–2014.

While it could be argued that the diagnosis of diabetes is skewed because routine testing by HbA1c was done in the LG, this is not true for the diagnosis of hypertension.

Prescribing patterns

The change in the pattern of disease has obviously led to changes in prescribing patterns. For the HG, no data is available. For the OG, some data can be compared with the LG.

For the LG, 9,878 items were prescribed for 2,937 refugees, giving an average of 3.36 items per refugee.

Figure 5 shows the distribution of the number of items per person. The vertical axis is the number of refugees, and the horizontal axis is the number of items (ie, 830 refugees received one item, 630 two items and so on).

Figure 5: Prescribing patterns, LG, 2010–2014.

Table 18: Comparison of some medications pre-scribed, between OG and LG, absolute numbers.

Interventions by primary care doctors

As well as a screening service, MRRC provided a separate primary care service provided by primary care doctors from 2006. A screening clinician might provide some minor primary care (eg, prescribing for iron deficiency), but ongoing or more complex matters would be followed up by a primary care doctor at the clinic.

Data for HG and OG was not available. For LG, each primary care doctor recorded any intervention for the refugee on their appointment timetable in the patient management system. This may have been an actual face-to-face consultation, or a phone call to a specialist, or prescribing, and so on. For the purpose of this analysis, each entry is called an ‘intervention’.

The appointment books of the primary care doctors were analysed. In all, 2,438 refugees received 6,945 interventions, an average of 2.85 interventions per refugee recorded. Given that the group analysed was 3,530 in number, this means that 70% of refugees received some form of intervention from the primary care doctors, as well as receiving routine screening.

Figure 6 shows the interventions by numbers, similar to the chart for medicines above (ie, 760 refugees received one intervention and so on).

Figure 6: Interventions per refugee, LG.

Secondary services referrals

In many ways, comparisons between the original and later groups are difficult, as the populations are different and some ways of working were very different between the two times.

However, the figures give a broad-brush picture. The data from the original group has been re-worked to enable comparisons to be made, and to correct an error, where the referral number for paediatrics was ascribed to general medicine.

Table 19: Referral to secondary services, original group and later group.

Table 20: Quick comparison of certain diseases, 1980–2014.

Table 21: % of refugee population affected by diabetes.

Conclusions and discussion

In November 1979, not long after MRRC had opened, the medical officer in his annual report wrote, “The refugees in our first few intakes were…infested with external and internal parasites and bacteria to an alarming degree…Exempting (sic) the normal run of coughs, colds and other minor ailments, the refugees…have been singularly free from any illnesses requiring specific treatment….”

In the 40 years since that was written, there has been a major change in the health profile of refugees resettling in New Zealand, especially in the last few years. This is a global phenomenon that has had and will have implications for staffing and the management of medical issues in resettling refugees.

Refugees are no longer “infested” with internal parasites, though there is still a significant number with gut parasites, especially those from refugee camps (see the section on Burmese refugees above). Refugees now have significant rates of non-communicable diseases (NCD), of which hypertension and diabetes are exemplars explored in this paper (Table 20). The latest data from the calendar year 2019 show that this trend is stable (Table 21). There are of course other NCD, such as coronary artery disease and cerebrovascular accidents, but their analysis is more complex and does not add to the main message. Note on cancer: cancer is not a common disease found in arriving refugees, and their short stay of only six weeks makes diagnosis during their stay unlikely, so cancer in refugees is beyond the scope of this paper.

Non-communicable diseases usually require greater management issues than parasites. Putting it simply, the usual geohelminths such as hookworm can be treated with a single course of a cheap antiparasitic. They do not self-replicate internally, and have a limited life span, so continuation of infection requires periodic re-infection. This being so, in a country with good water and sewage, even if treatment is not successful, the infection will die out of its own accord.

By contrast, an NCD such as diabetes requires a lifetime of commitment by patient and therapist. Figure 6 shows the number of interventions per refugee needed by a primary care doctor in addition to routine screening, and it confirms that a high proportion of refugees need additional interventions and those with complex problems require a large numbers of interventions.

The NCD in the historical group, 1979–1991, were extraordinarily low. Was this because the medical officers failed to detect or record them? In their annual reports, they were meticulous about recording demography, notifiable and non-notifiable illnesses and other general medical problems. In preparation for another publication,2 the author had access to the early paper records and can confirm that the medical officers completed the then-standard NZIS medical immigration form, which of course included measurement of blood pressure and the usual health screening questions.

The burden of NCD in refugees in modern times has been well recognised in New Zealand and elsewhere.10,11 It has been pointed out that the focus of refugee health has been on infectious diseases,12 and that addressing NCD in refugees in a timely manner is ultimately less expensive than deferring or trying to restrict treatment for them.13

Deficiency diseases have tended to decrease, as seen in iron deficiency, but still need follow-up—particularly vitamin D and B12 deficiency in some groups (see Table 9 and Table 10). These deficiencies in refugees are well recognised.14–16 The absence of folic acid deficiency in the LG compared with the OG is difficult to explain and there seems to be no explanation in the literature.

Perhaps the most successful reduction is that of tuberculosis. In the historical group, the overall prevalence was 4%, which represents a point prevalence of 4,000/100,000. The medical officers reported prevalence of up to 12% in some exceptional intakes. In the original group, the prevalence had fallen to 2%, which is still 2,000/100,000. This fall must represent improved health in the refugees overseas, and in the later group, the prevalence had fallen to 0.18%. By this time refugees were being x-rayed and treated overseas for tuberculosis. This is a point prevalence of 18/100,000. The average annual incidence of tuberculosis in New Zealand was reported as 6/100,000 in 2016. The highest rates were found in the Asian ethnic group (32.7/100,000), and in the Middle Eastern, Latin American and African (MELAA) it was 17.2/100,000, which is comparable to that found in the refugees.17

Another success is the reduction of intestinal parasites, from rates reported as greater than 45% by the medical officers in some intakes in the historical group, to 30% in the original group and 17.4% in the later group. The section considering Burmese refugees shows that some of this reduction may be due to accommodation outside refugee camps. An unknown number of refugees have also been treated for parasites before departure, which can be very effective in reducing the burden of parasites in re-settling refugees.18

Why has there been such a change in the origin of the refugees, and what effect has it had?

The change is due to (1) A changing world situation and (2) political decisions in New Zealand.

The variation in origin of the refugees resettling in New Zealand is described in certain publications22 and is a history of the conflicts of the world, writ small. Many of the refugees in the historical group came from Vietnam, an area in which conflict seemed to be without end at the time, but which is now a desirable tourist destination.

A political decision was made in New Zealand to restrict refugees from Africa and the Middle East,20 but this was relaxed in 2015, to allow an emergency intake of refugees from Syria, and abolished in 2019.21

The change in the origin of refugees had an effect on the prevalence of such conditions as HIV, schistosomiasis, strongyloidiasis, hepatitis C and vitamin B12 deficiency.

Another variation which is not revealed by this study, but with which any worker with refugees will be familiar, is the variation in health literacy and previous access to care in a single intake. On the one hand, there may be refugees with very limited health literacy, for whom the explanation of hereditary haemolytic disorder is difficult; and on the other hand, a refugee may present their CD of their whole-body CT scan and request that it be repeated.

Also, on the one hand, there may be a refugee from a refugee camp with one or two small plastic packets of individual medicines, enough for a week or so, and on the other, a refugee with a large plastic bag full of medicines in their original containers, often bought over the counter and not prescribed.

The higher prevalence of abnormal cervical smears in the later group is probably multifactorial. For example, improved screening methods, a change in population and so on. Its analysis is beyond the scope of this paper. One study found the percentage of abnormal smears in refugee women varied from a low of 3% to a high of 10%, depending on ethnicity.23

Referrals to secondary services (Table 24) show many similarities between the original group and later group. The high rates of referral to secondary services should not be taken to show that refugees are necessarily an unhealthy group, but rather that their healthcare has been ‘frozen’, often for many years, and the number of referrals can be seen as a catchup phenomenon.

For most services, the numbers are much the same between the original and later groups.

Notable differences exist between:

1. infectious diseases: greater in the original group
2. imaging: greater in the original group
3. mental health: less in the original group
4. sexual health: greater in the original group
5. gynaecology: less in the original group
6. diabetes clinic: less in the original group.

(1) Infectious diseases can be explained by the different populations. Most striking are referrals to paediatric infectious disease services. The majority in both groups are to the paediatric TB service as the result of Mantoux testing. In the original group, almost six times as many children were referred for non-TB related infectious diseases, the majority of these being for active schistosomiasis, which does not exist in the populations of the later group.

(3) Mental health can be explained by the increased availability and expertise of the counselling service, Refugees as Survivors New Zealand. In the later group, all referrals were to this service and none to outside psychological services. In the original group, 20 referrals were to outside psychological services and the remainder to Refugees as Survivor, which started operating in 1995.

(5) Gynaecology: The difference is mostly related to the increased rate of abnormal cervical smears in the later group, with referral for colposcopy. Why there is an increased rate of cervical smears in the later group is not clear, but it does seem to be a gradual trend over the years.

(6) Diabetic clinic can be explained by the completely different structure of the clinical team and modern management of diabetes. The clinical team for the original group had no dedicated general practitioners, and diabetes management was the preserve of outpatient clinics; with its increased prevalence, diabetes management is now the stock in trade of general practice services; dedicated general practitioners were appointed to the clinical team for that reason, and the management of other chronic diseases.

This again raises the question of the impact on service provision of the different health profile of modern refugees with their increased rate of NCD; the changes in the staffing at the medical clinic between 1979 and 2014 is instructive in this regard.

When the clinic opened in 1979, and the annual intake was 750 refugees, the clinic was staffed by:

• two part-time doctors, 0.9 full-time equivalent (FTE)
• one full-time nurse, 1.0 FTE
• one full-time clerk/administrator, 1.0 FTE.

Dental services were provided by a dental unit of the territorial army. By 2020, when the Auckland District Health Board relinquished running the clinic and the annual intake was 1,000 refugees, the staffing was:

• two part-time doctors for screening, 1.2 FTE
• three nurses, two screening, all three sharing nursing duties, 2.6 FTE
• three admin staff, 2.5 FTE
• four visiting doctors, providing mostly general practice services and a little screening, 0.8 FTE
• dentist and dental assistant, 0.2 FTE each, from hospital dental department.

At the time it was felt that the general practice service FTE was less than was needed for optimal care.

The impact of the change in health profile is documented in this study by Tables 21 and 22, showing the rates of prescribing and the kinds of medication, and in particular Table 23, which shows the ‘interventions’ where it should be re-affirmed that this is over a six-week timetable.

The causes for the increase in NCD are probably multiple. This study shows, on the one hand, an encouraging reduction in the use of tobacco, but on the other hand, a general increase in BMI.

The new way of caring for refugees aims to screen them overseas rather than in New Zealand, provide care for any NCD found at the time of screening overseas, continue that care on arrival at MRRC and pass such care seamlessly onto the general practitioners in the receiving towns and cities, some of whom will not have dealt with refugees in the past. The exact configuration of the new medical clinic is not known, but aims to substantially increase general practice care.5

This study does have its limitations. In particular, a lack of analysis of mental health issues, which represent a substantial burden for many refugees. The provision of mental health care for resettling refugees would be regarded as being vital.

Other limitations include social/lifestyle issues, such as origin from refugee camp or otherwise, language, education levels, health literacy, drug and alcohol use, gambling, domestic abuse and previous medication uses.

In summary, there has been a major change in the health profile of refugees resettling in New Zealand between 1980 and 2014 and beyond, from a population with high rates of parasitic and bacterial infection and low rates of non-communicable diseases, to one where infection is much less, though not absent, and high rates of non-communicable diseases. This is not unique to New Zealand and will have an impact on the provision of healthcare for refugees, here and elsewhere.

The bottom line is this: health practitioners who are new to caring for resettling refugees might be worried that they might have to deal with unfamiliar and exotic tropical diseases; the truth is that most of their work will be with the familiar non-communicable diseases, in the context of an unfamiliar population group.